Provider Demographics
NPI:1518160316
Name:EAST MAIN VISION CLINIC LLC
Entity Type:Organization
Organization Name:EAST MAIN VISION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:253-770-2732
Mailing Address - Street 1:2732 E MAIN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-3164
Mailing Address - Country:US
Mailing Address - Phone:253-770-2732
Mailing Address - Fax:253-770-1023
Practice Address - Street 1:2732 EAST MAIN
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372
Practice Address - Country:US
Practice Address - Phone:253-770-2732
Practice Address - Fax:253-770-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-08
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1704TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032936Medicaid
WATO02018Medicare UPIN
WA6029120001Medicare NSC